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Earl Howe: I am extremely grateful to the Minister for answering in that very full way, given the embarrassing circumstances in which I find myself. I owe her an apology from these Benches because we have misplaced these amendments in the Bill; indeed, they clearly should have gone somewhere else. So I express many thanks to the Minister, and especially for what she said about the Government's approach to the Nolan rules. That is most helpful. I believe that that principle has generally found favour around the Committee.

I should like to say a few words to the noble Lord, Lord Warner, about my noble friend. Not only is she unable to be present here this evening but she is also extremely ill. I feel that I should say in her defence--as she made clear at the time that that remark, which the noble Lord referred to, appeared in the press--that it was not that she had been actively discriminating against the Labour Party: it was that whenever she made an appointment she took absolutely no account of what party the person was a member of. I felt that I should make that clear, as my noble friend did at the time,

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because the remark has been taken grossly out of context in quite the wrong way. I consider it my duty to defend my noble friend as she is not here to do so for herself. Having said that, I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

[Amendment No. 59 not moved.]

Clause 5 agreed to.

Clause 6 [Payments relating to past performance]:

Earl Howe moved Amendment No. 60:

Page 6, line 21, at end insert--
("(3CC) The objectives referred to in subsection (3C) above shall not include Health Authority or NHS Trust performance with regard to waiting times for out-patient consultations or waiting lists for surgery.").

The noble Earl said: This amendment addresses an issue which relates once again to political interference in clinical decision-making. The waiting list pledge in the Government's election manifesto, which the Government kept on referring to as an early pledge--although quite what is early about it I do not know--seems to me a complete millstone around their necks. It is a millstone not only because waiting lists are a false indicator of patient need, but also because they are having to move heaven and earth to achieve the pledge to cut waiting list numbers by 100,000 below the figure that they inherited. The recent trends in the waiting lists for surgery have been downwards. However, as the official figures show, this has been achieved, at least in part, by increasing the length of time that patients have to wait to get onto the waiting list in the first place. That has been brought about by placing pressure on clinicians to hold fewer clinics and more surgical sessions. The result is that there are fewer hours in the day when they can see patients to determine whether they should go on the waiting list for surgery. That build-up is more serious than a build-up on the waiting list proper because urgent cases cannot be assessed or prioritised.

But waiting lists have also been cut by means of artificial diktats on routine operations. In many health service regions some operations are simply no longer available. I refer to operations for non-acute varicose veins, lipomas, sebaceous cysts and hernias, for example. Perhaps more seriously, we are seeing quick, simple procedures being performed ahead of more complex and often more serious operations. If you can improve the turnover of cases, the bare numbers recorded as "waiting" will, of course, fall. But what does that do to the principle that doctors and consultants live by, that clinical need should determine priorities? The priorities are being distorted in other ways too. However, my vow of brevity prevents me from cataloguing them. But the point is a straightforward one. It is truly bad when political imperatives from the centre come between the doctor and his patient. I beg to move.

Baroness Hayman: It is probably not the time of night to start arguing the toss with the noble Earl about the waiting list pledge made in our manifesto which we intend to keep and which I believe is of major importance to patients. I shall simply say that he is right to point out the increased demand for outpatient

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appointments but not right to suggest that this is caused by an irresponsible concentration on in-patient work. What we have seen is a vast increase in the number of referrals. There are more out-patient sessions and more out-patients being seen; there are more in-patients being seen; and more emergency cases are being treated. It is not a case of one section of work displacing another.

When we discuss "the waiting list for the waiting list" it is important to recognise that not everyone who attends an out-patient appointment will go onto a waiting list for an in-patient appointment--that happens only to about 50 per cent. of patients. Some of the biggest increases in out-patient waiting times have been in specialities such as dermatology which seldom occasion in-patient treatment. With the greatest of respect, I suggest to the noble Earl that he has grossly oversimplified the situation. That covers the general point.

As to the amendment, the aim of the clause is to allow the Secretary of State to introduce a scheme for rewarding those health authorities that make good progress against the targets and the objectives laid down in their health improvement programmes. I stress that they are laid down in the health improvement programme--which is very much a joint enterprise--rather than in some political diktat from the centre.

It is crucial that the Secretary of State is able to take into account the full and wide range of factors necessary to judge health authorities' success in improving the health of their local communities and tackling local health inequalities. The Bill must not therefore dictate which of the health improvement programme targets can be considered or constrain which objectives can be used.

The amendment, if accepted, would result in a loss of flexibility around the objectives against which that performance could be assessed. As such, it would undermine the ability of the Secretary of State to tailor a rewards scheme to support health improvement in the areas that he felt to be the most deserving of support.

I can reassure the Committee that the powers derived from this clause will not be used simply to reward the best performing health authorities. They will reward those authorities which make good progress against the targets of their health improvement programmes. That will mean that health authorities will be judged on their own relative performance and all authorities--including those starting from a low baseline--will be eligible. The scheme will not, therefore, simply allocate additional monies to those health authorities with the shortest waiting lists, and will not ignore those areas where waiting lists remain longer.

We wish to reward health authority success across the full range of health improvement programme targets. I hope the Committee will agree that it would therefore be inappropriate to include this sort of constraining detail on the face of the Bill.

10.45 p.m.

Earl Howe: Once again I thank the Minister for her very full reply. I shall study carefully what she has said. It is no part of my intention ever to over-simplify and therefore perhaps misrepresent an argument--I certainly

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would not wish to do that. Nevertheless, I still believe that the position is extremely serious. I shall be very surprised if we do not return to the matter on a future occasion. For the time being, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Sharp of Guildford moved Amendment No. 61:

Page 6, line 38, at end insert--
("(3G) Where the Secretary of State reduces the allotment to any Health Authority, he shall publish details of the reasons for the reduction."").

The noble Baroness said: The amendment is aimed at greater transparency. A month ago, in the general debate about the National Health Service, I spoke about the financial difficulties of my own local health authority, the West Surrey Health Authority. At present--as with much local government finance as well as with National Health Service finance--precisely how the total NHS budget is divided up between different health authorities is, for many people, a total mystery. The noble Baroness, Lady Fookes, a short while ago, spoke about the advantage of having a clear framework against which performance can be judged.

We would like to see more information in the public domain as to why decisions have been taken. A requirement to publish details of the reasons for any reduction in budget should ensure consistency of treatment between one health authority and another, and help to promote a greater understanding among the general public of the rationale underlying such resource allocations. I beg to move.

Baroness Hayman: I can quite understand the rationale behind the amendment moved by the noble Baroness. I would suggest to her that its import is not helpful. The amendment would mean that the Secretary of State would have to publish details of why he had clawed back some or all of the additional allocation awarded to a health authority on the basis of its past performance, where it had failed to deliver.

The aim of the clause as it stands is to allow the Secretary of State to introduce a scheme for rewarding those health authorities which make good progress against targets and objectives laid out in the health improvement programme, as I said when dealing with the previous amendment. As part of the process for selecting those health authorities to be rewarded, eligible authorities will be required to submit costed outlines of exactly how they propose to use the additional moneys and which elements of their health improvement programmes they wish to bring forward. It would not be sensible to include every detail of that on the face of the Bill.

I can perhaps reassure the noble Baroness that the intention to withdraw funds would arise only if they were misspent or not applied to the purpose for which they were agreed. I can perhaps further reassure her that the Secretary of State would make clear in letters to health authorities the reasons for any reduction in their

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allocations. There would therefore be an element of transparency. I hope that that will be enough to reassure the noble Baroness.

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